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BioMed Central Page 1 of 19 (page number not for citation purposes) Implementation Science Open Access Research article Institutionalizing evidence-based practice: an organizational case study using a model of strategic change Cheryl B Stetler* 1 , Judith A Ritchie 2 , Jo Rycroft-Malone 3 , Alyce A Schultz 4 and Martin P Charns 5,6 Address: 1 Health Services Department, Boston University School of Public Health, Independent Consultant, 321 Middle St, Amherst, MA 01002, USA, 2 McGill University Health Centre & School of Nursing, McGill University, Montreal, Quebec, CA, 3 Centre for Health-Related Research, School of Healthcare Sciences, Bangor University, UK, 4 Alyce A Schultz and Associates, LLC, 5747 W Drake Court, Chandler, AZ 85226, USA, 5 VA HSR&D Center for Organization, Leadership and Management Research, Boston, MA, 02130 USA and 6 Health Policy and Management Department, Boston University School of Public Health, Boston, MA, 02118 USA Email: Cheryl B Stetler* - cheryl.stetler@comcast.net; Judith A Ritchie - judith.ritchie@muhc.mcgill.ca; Jo Rycroft-Malone - j.rycroft- malone@bangor.ac.uk; Alyce A Schultz - alyceme@cox.net; Martin P Charns - mcharns@bu.edu * Corresponding author Abstract Background: There is a general expectation within healthcare that organizations should use evidence-based practice (EBP) as an approach to improving the quality of care. However, challenges exist regarding how to make EBP a reality, particularly at an organizational level and as a routine, sustained aspect of professional practice. Methods: A mixed method explanatory case study was conducted to study context; i.e., in terms of the presence or absence of multiple, inter-related contextual elements and associated strategic approaches required for integrated, routine use of EBP ('institutionalization'). The Pettigrew et al. Content, Context, and Process model was used as the theoretical framework. Two sites in the US were purposively sampled to provide contrasting cases: i.e., a 'role model' site, widely recognized as demonstrating capacity to successfully implement and sustain EBP to a greater degree than others; and a 'beginner' site, self-perceived as early in the journey towards institutionalization. Results: The two sites were clearly different in terms of their organizational context, level of EBP activity, and degree of institutionalization. For example, the role model site had a pervasive, integrated presence of EBP versus a sporadic, isolated presence in the beginner site. Within the inner context of the role model site, there was also a combination of the Pettigrew and colleagues' receptive elements that, together, appeared to enhance its ability to effectively implement EBP- related change at multiple levels. In contrast, the beginner site, which had been involved for a few years in EBP-related efforts, had primarily non-receptive conditions in several contextual elements and a fairly low overall level of EBP receptivity. The beginner site thus appeared, at the time of data collection, to lack an integrated context to either support or facilitate the institutionalization of EBP. Conclusion: Our findings provide evidence of some of the key contextual elements that may require attention if institutionalization of EBP is to be realized. They also suggest the need for an integrated set of receptive contextual elements to achieve EBP institutionalization; and they further support the importance of specific interactions among these elements, including ways in which leadership affects other contextual elements positively or negatively. Published: 30 November 2009 Implementation Science 2009, 4:78 doi:10.1186/1748-5908-4-78 Received: 23 October 2008 Accepted: 30 November 2009 This article is available from: http://www.implementationscience.com/content/4/1/78 © 2009 Stetler et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Implementation Science 2009, 4:78 http://www.implementationscience.com/content/4/1/78 Page 2 of 19 (page number not for citation purposes) Background Organizational context is receiving attention from researchers across multiple disciplines as a potential factor in the successful implementation of evidence into practice [1-5]. Although individual-level determinants of research use have received primary emphasis historically, findings from the fields of quality improvement (QI), research uti- lization (RU), and evidence-based practice (EBP) increas- ingly are demonstrating that a number of contextual factors may also play an influential role. More specifically, contextual factors at micro-, meso-, and macro-levels, such as leadership [6-10], culture and climate [11,12], access to resources [13,14], team climate [15], organiza- tional slack [16], and organizational support [17,18] have emerged as potential mediators. Despite this growing evidence base, we still do not know which contextual factors are more important, or how they operate or inter-relate to result in the successful imple- mentation and use of evidence in practice. Furthermore, much of the existing research has been conducted with a focus on isolated practices or guideline and procedure- focused projects. There is little implementation research that focuses primarily on the overall context itself or, more specifically, on contextual factors related to institu- tionalization of EBP as a routine way of practicing (See def- initions, Appendix 1). If one considers EBP institutionalization as an example of a strategic organiza- tional transformation, then Harrison and Kimani's obser- vations seem relevant to this knowledge gap [19]; i.e., 'accounts of transformation initiatives often reveal little about past organizational and contextual conditions that contributed to success. Instead, these accounts concen- trate on change barriers.' While there are exceptions in the research literature [20,21], and pragmatic cases can be found where selected organizations are moving forward to routinize EBP [22-24], rarely are rigorous evaluations of related contextual and strategic processes presented. In summary, we know little about what specific set of contex- tual conditions interact to facilitate the institutionaliza- tion of EBP [25]. Against this background, there continue to be calls for more research. For example, there is a need to enhance our level of understanding of context sufficient both to guide organizational-level intervention studies as well as individual improvement/implementation practice change projects [1,11,26-28]. There is also a need to better under- stand configurations and the related combined presence or absence of contextual factors in relation to an organiza- tion's capacity to improve [29]. This paper presents the main findings from a case study addressing such gaps in the literature. Specifically, this theoretically-based study sought to identify key contextual elements and related configurations and relationships in an organization where EBP was perceived to be used routinely, in contrast to one in which it was not. Study purpose and framework A published protocol [25] provides in-depth information about this study's background, theoretical framework and methods. This section of the paper provides a summary. The study's primary research questions were: 1. What key contextual elements support and facilitate institutionalization, i.e., routine implementation of EBP and related projects, within a healthcare system at multi- ple institutional levels? 2. What strategic processes are used to create institutional- ization of EBP within a healthcare system at multiple institutional levels? The Content, Context, and Process model of the strategic management of change [30-35] was the study's theoretical framework. It has the following components: 'Elements' or signs and symptoms of receptivity related to more suc- cessful strategic change; and 'essential dimensions' of stra- tegic change, i.e., the WHY/motivation for change, the HOW/process of change, and WHAT/content of change. The framework also allows differentiation between a receptive and a non-receptive context. A receptive context has 'features (and also management action) that seem to be favourably associated with forward movement'; and a non-receptive context has 'a configuration of features which may be associated with blocks on change' [34]. Methods The study was a multi-method explanatory case study [36], with a core qualitative component and simultaneous supplementary quantitative component [37]. It focused on exploring the role and evolution of context in the rou- tine use of evidence in practice within targeted services ('case'). A case was a department of nursing within a hos- pital. Sampling and recruitment Sites Two sites from different regions of the United States (US) were purposively selected to provide contrasting results for predictable reasons [36]. First, a 'role model' site was selected through a nomination process involving the American Organization of Nurse Executives (AONE) [25]; i.e., members of relevant AONE Boards were asked to identify ' widely recognized acute care hospital-based nursing departments that appear to have demonstrated the capacity to successfully implement and sustain EBPs to a greater degree than other nursing departments in the Implementation Science 2009, 4:78 http://www.implementationscience.com/content/4/1/78 Page 3 of 19 (page number not for citation purposes) US , that is, nursing departments that appear to under- stand 'how to make EBP happen' and are seen as a role model by other nurse executives.' (See Additional File 1, 'Nomination panel letter for role case.') The selected department met the criteria of high ranking by the AONE panel; high self-rated level of institutionalization, with a brief substantiating rationale; and willingness to partici- pate in the study and facilitate site access. Second, a 'beginner' site was selected from AONE member volunteers self-reporting their department as 'early in the journey to institutionalization.' The selected site had low self-rated institutionalization, with a brief substantiating rationale, and willingness to participate in the study and facilitate site access. From among all volunteers, this site was a best match with the role model hospital's character- istics (Table 1). Site participants Participants within each site were identified in two ways. Three embedded units within each site (medical/surgical, specialty, critical care) provided a pool of staff nurse par- ticipants. Second, within each site, a list of members of the hospital-wide nursing leadership/management team and other relevant EBP key informants was created by the site facilitator and local study sponsor, in collaboration with Table 1: Chief characteristics of the case study sites Characteristic Role model site Beginner site Bed size Over 350 Approximately 400 In-patient units 20 24 Type of hospital Academic medical center Community hospital (With multiple nursing school affiliations) Chief nursing officer authority Full administrative authority, with financial resources control Full administrative authority, with financial resources control Chief nursing officer type of position A vice president of patient services in general, with responsibilities beyond nursing A vice president of patient services in general, with responsibilities beyond nursing Magnet status Magnet designated hospital Magnet application hospital Other status Non-Union Non-Union Self-perceived EBP status upon selection More than three-fourths progress* along the scale toward full EBP integration Also self-reported: 'an intense focus on EBP' Not even one-fifth progress along the scale* toward full EBP integration: Also self-reported: 'implemented some EBP initiatives basic, nothing high level' Case mix index, all payors At the time of their site visit, both hospitals reported case mix indices in the low to medium intensity of resource use, with the role model site** reporting lower resource needs more similar to that of community hospitals, and the beginner site experiencing resource use suggesting moderate needs, higher than most community hospitals but lower than tertiary medical centers. Nursing education mix The role model site had a very high proportion of BSN nurses, virtually double that of the beginner site. Hours per patient day (HPPD) ▪ Critical care: Last quarter (Jan-Mar 07) 19.8 ▪ Critical care: 14.62 ▪ Med-surg: 9.92 ▪ Med-surg: 5.22 *EBP Journey Scale START - Starting to consider our EBP goals/vision END - EBP is fully integrated into our structures and routines **Role Model Site CMI: The role model site described a concern that their CMI did not reflect their level of patient acuity. After our study, the site had its CMI reassessed by DRG specialists and recently reported to us a new CMI, which is considerably higher than that used above and is now at a level consistent with their status as an academic medical center and their HPPD. Implementation Science 2009, 4:78 http://www.implementationscience.com/content/4/1/78 Page 4 of 19 (page number not for citation purposes) the principal investigator/PI (CBS). This list included both formal leaders, i.e., those in managerial positions at all levels of the hierarchy, and informal leaders, i.e., those in support/staff positions as well as other individuals per- ceived to influence EBP at either central or unit-based lev- els. Such informal leaders included educators, researchers, various specialists (such as clinical nurse specialists/CNSs, or QI resources), chairs or facilitators of EBP groups, and others viewed as 'leaders in EBP.' In particular, bedside nurses perceived to influence EBP, and thus defined in the study as informal EBP leaders, were sought. A purposively sampled set of all types of leaders was drawn from this list for individual interviews [25]. Data collection methods 1. Individual interviews with leaders and focus group interviews with staff nurses: Interview questions were pri- marily developed within the framework's essential dimen- sions of the WHY, WHAT and HOW of strategic change [25]. 2. Focused observations of pre-formed nursing and inter- disciplinary groups relevant to EBP initiatives and natu- rally occurring at the time of the site visit, e.g., policy/ procedure committee. 3. Document review of relevant EBP information, e.g., role descriptions [25]. 4. Field notes from site visits by investigators. 5. Surveys including organizational learning survey/OLS for culture [38], multi-dimensional leader questionnaire/ MLQ [39], nursing work index/practice environment sur- vey/PES [40], and a research utilization (RU) tool [41], along with demographic information. Surveys were col- lated into a package and sent to all listed formal and infor- mal leaders, as well as all staff nurses on the embedded units. Leaders were asked to focus their responses based on assessment of the chief nursing officer/CNO (MLQ), department as a whole (PES and OLS) or staff nurses as a whole (RU). Staff nurses were asked to focus their responses based on assessment of their unit (PES and OLS), nurse manager (NM)/ward sister (MLQ) or self behavior (RU). Analysis Qualitative data analysis Data were analyzed within site-specific data sets and then triangulated across site-specific data sets before making comparisons across sites. Analyses focused specifically on identifying content related to institutionalizing EBP. An initial coding scheme was developed deductively based on basics of EBP change (e.g., definitions and barri- ers) and elements and dimensions in Pettigrew [33,34]. In terms of the latter, in addition to WHY, WHAT and HOW sub-categories under strategic management of essential dimensions, eight receptive elements (Figure 1) formed the basis for another major coding category (receptive context for change). This included sub-nodes for 'recep- tive' and 'non-receptive' content, per element. An induc- tive approach also was used to allow for creation of emerging codes. Data were managed in NVivo. The role model site was coded first. This initial coding framework also applied to the beginner site data but required the addition of new sub-codes (e.g., Magnet and staffing). The PI took the main role in analysis, with other team members continuously checking/validating the approach and emerging findings. This often necessitated revisiting raw and coded data as well as clarifying and operationalizing definitions of contextual elements. The latter was needed as some of the framework's elements culture, leadership, and coherence (Table 2) did not have sufficiently clear definitions to enhance consistent coding decisions. Through this iterative team approach, agree- ment was reached on key findings and comparisons for each site. An audit trail was maintained throughout the analysis process. Triangulation Within the qualitative data analysis process, triangulation was used to refute or confirm emerging findings within each data set. For example, as leadership began to emerge as a key issue within interview data, this also was explored within focus group data and field notes. Findings from our qualitative data helped provide a focus for what to report from survey data. For example, given leadership's emergence as a key qualitative finding, we were interested to investigate MLQ findings. In this way, triangulation provided us with a validation process, thereby increasing the trustworthiness of our findings. Quantitative data analysis Numeric data analysis was managed in SPSS, Version 15. Analysis of each survey instrument was conducted sepa- rately and followed the analysis procedures recom- mended by the originators. Two-tailed, independent sample t-tests were used to test mean differences between sites overall and between their leadership. Staff nurse sam- ples were not compared statistically between sites due to their small size. Results Sampling Table 3 provides a description of the 'sample' for each site, for each type of data collection. Greater participation was experienced in the role model site, despite the heavy work Implementation Science 2009, 4:78 http://www.implementationscience.com/content/4/1/78 Page 5 of 19 (page number not for citation purposes) demands reported in both organizations. For example, at the role model site there were: proportionally more staff in focus groups and responding to surveys; more staff nurses who were identifiable as informal leaders, includ- ing special staff nurse roles relevant to EBP; and more groups with explicit links to EBP to observe. Overview of each case 'Role model' case Qualitative data showed that the role model site had been deliberatively and strategically building the capacity to successfully implement and institutionalize EBP over a period of more than five years. Within interview, focus group, field note, and document data, there was evidence of an approach that encompassed the essential dimen- sions of strategic change relative specifically to EBP. This included explicit attention to the WHY, or motivation/ rationale for and enablers/barriers to strategic EBP change; the HOW, or methods of strategic EBP change; and the WHAT, or operationalized infrastructures of stra- tegic EBP change [25] (Appendix 1). Priority given to EBP at the role model site was evidenced through verbal communications and recurrent EBP lan- guage; a multiplicity of key documents, e.g., a vision/mis- sion statement and role/performance expectations; a continuous record of nurse-initiated EBP projects and research, and ongoing, norm-related managerial initia- tives (see EBP-related documents, Table 3). As one inter- viewee commented, 'EBP in your face every day but in a good way' (formal leader three). From an historical per- spective, Magnet Recognition Program ® status (Appendix 1) was sought at basically the same time as the EBP effort was initiated. Further, the most influential, top EBP lead- ers were of long-standing tenure at the time of the site visit and had been present from the start or before the initia- tive; and visible progress and continuing, deep commit- ment to EBP were evident by years three to four. 'Beginner' case Qualitative data showed that the beginner site was a department in transition and at the time of the study visit, as initially self-reported, still early in the EBP institution- alization journey. Leaders in some cases felt they had made progress during the intervening period between selection and study visit. However, it should be noted that the so-called 'beginner's' focus on the Magnet Recognition Program ® , which references EBP, was reported to have begun more than three years earlier; and although at the time of the visit there was evidence of a clear intent to build capacity to successfully implement EBP, most struc- tural attempts as noted in analysis of interview, focus group, field note, and document data had yet to be ade- quately operationalized and thus realized as a routine, day-to-day activity. It is also of note that the two top lead- ers at the beginner site, comparable to the noted EBP Receptive contexts for changeFigure 1 Receptive contexts for change. Reproduced with permission of Wiley-Blackwell: Pettigrew A, Ferlie E, McKee L: Shaping Strategic Change The Case of the NHS in the 1980s. Public Money & Management 1992, 12(3):27-31 (Figure 1, p 29). Implementation Science 2009, 4:78 http://www.implementationscience.com/content/4/1/78 Page 6 of 19 (page number not for citation purposes) influential leaders at the role model site, arrived after the initial Magnet work had begun. EBP was rarely articulated by beginner site study partici- pants as an ongoing explicit priority or vision. As one key leader noted, 'I don't think we have a clear vision and stra- tegic plan for how we are going to use this.' Interviewer: 'In terms of EBP?' Key leader: 'Exactly. Exactly.' Instead, a clear priority at the time of data collection was achieve- ment of 'Magnet' status (Appendix 1): 'We've been doing Magnet rounds for, I don't even know how long. We go on rounds to talk about Magnet, to answer any questions that they might have ' (informal leader thirteen). Outcomes were also designated as a clear priority, but again not in a way that was clearly connected to EBP. Overall, based on multiple sources of data, it was the judgment of the study team that the Magnet effort seemed to detract some key players from the EBP institutionalization aspect of the ini- tiative, rather than reinforce it. Further, data showed that some key leaders at the begin- ner site focused more heavily on the conduct of research rather than its use, which is consistent with the Magnet Recognition Program ® . The department also tended to focus on an organization-wide priority of collecting QI audit and outcome data, which was heavily geared to externally defined performance indicators (e.g., from Centers for Medicare/Medicaid Services). Although intended to enhance quality, such data or related collec- tion activities were perceived by multiple participants as Table 2: Elements of receptivity Pettigrew et al. elements [34] Study definition and observations Change agenda and its locale The element's focus is on the fit between the agenda and factors in the local, external environment that might influence internal change efforts. Cooperative inter-organizational networks Development and management of links with other agencies, e.g., through boundary spanners. (Long term) Environmental pressure The intensity and scale of pressures from influential agents external to the organization. Key people leading change • Defined by the team in terms of roles in which an individual influences others, more specifically, in terms of strategic versus operational influence, i.e., influencing others to behave in certain ways toward preconceived group goals (Schein) ___ in this case EBP in a department of nursing. • Types of roles were defined as formal, or managerial and related to positions of authority at all levels; or informal. Informal leaders included both clinical support personnel, such as APNs (Advance Practice Nurses) and special types of staff or EBP roles, either formal or informal. Quality and coherence of policy • The meaning of policy is broad, e.g., in the form of a broad vision, and not specifically about local policies and procedures. • More focused on strategic decisions relative to change, with quality referring to the related evidence base, related conceptual thinking about such decisions, and eventual buy-in • Coherence reflects initial exploration of a vision's congruence among related 'goals'; attention to politics and needed negotiation with key stakeholders; feasibility; and skill in terms of how the targeted strategic change was managed. In this study such congruence was defined as not only including development/refinement of organizational components on paper but the actual operationalization of such infrastructures for EBP; i.e., organizational structures, systems, roles, processes, relations, alignments, and capabilities. Managerial-clinical relations The quality of the interface between staff and management. Simplicity and clarity of goals • The ability 'to narrow the change agenda down into a set of key priorities, and to insulate this core from the constantly shifting short-term pressures' [34]. • Demonstrates managerial ' persistence and patience in pursuit of objectives over a long period' [34]. Supportive organizational culture Defined by the study team as the way things are done in an organization that is supported by its values, norms and expectations. Such forces in an organizational social system affect behavior of individuals. Culture can be characterized as strong or weak. In an organization with a strong culture there is high agreement among individuals regarding expectations and values, whereas the level of agreement regarding values and expectations is low or highly variable in a weak culture. Regarding EBP, values and expectations regarding use of evidence are direct aspects of a culture supporting evidence based practice. Related characteristics of a culture, such as values supporting collaboration and teamwork, are expected to support EBP. Implementation Science 2009, 4:78 http://www.implementationscience.com/content/4/1/78 Page 7 of 19 (page number not for citation purposes) Table 3: Summary of case site samples SOURCES OF DATA ROLE MODEL SITE N/TYPE PARTICIPANT BEGINNER SITE N/TYPE PARTICIPANT FOCUS GROUPS: on three units per case Focus Group interviews = 9 Focus Group interviews = 5 • General med/surg unit; specialty unit; and a critical care unit. Total staff nurse participants, multiple shifts = 27 Total staff nurse participants, multiple shifts = 14 • All staff, per unit, invited to one of several sessions. LEADERSHIP INTERVIEWS: Total leadership interviews = 30 Total leadership interviews = 29 • Primarily formal leaders within nursing but also physicians, allied health and non-nursing top leaders. Number of individual leaders = 26 Number of individual leaders = 28 • Informal leaders, primarily nursing • FORMAL: 14 • FORMAL: 14 - Top organizational leaders, e.g., chief nurse; her 'supervisor'; and chief MD - Top organizational leaders, e.g., chief nurse; her 'supervisor'; and chief MD - Nursing clinical directors and nurse managers; and non-nurse clinical director and non-nurse manager, e.g., allied health - Nursing clinical directors and nurse managers; and non-nurse clinical director and program leader, e.g., allied health - Nursing support or clinical resource services manager and non-nurse support service director - Nursing support or clinical resource services manager and non-nurse support service director - Some also chairs of EBP-related committees/groups - Some also chairs of EBP-related committees/groups • INFORMAL: 12 • INFORMAL: 14 - Nursing support or clinical resource staff, such as researchers, APNs, or other various specialists relevant to EBP - Nursing support or clinical resource staff, such as researcher or APN • Special staff nurse roles relevant to EBP on non-embedded units such as champion/ facilitators or data/outcome specialists; some were also charge nurses - Other various specialists relevant to EBP either within or outside of nursing, such as condition-specific educator or data/ outcome specialists • Staff nurses involved in a special project or governance-related group; and an expert nurse GROUP OBSERVATIONS Groups = 5; Total participants = 74 Groups = 3; Total participants = 16 • Policy/procedure-related and inter- disciplinary • Policy/procedure and inter-disciplinary • Interdisciplinary clinical group • Special QI group • Two special EBP groups, one interdisciplinary • Nursing leadership group • Shared governance (PI invited) EBP-RELATED DOCUMENTS • A multiplicity related to infrastructures, including, e.g., • Some related to infrastructures, including, e.g., - Philosophy and mission - Philosophy - More than a dozen on role descriptions and appraisal; clear focus in career ladder program - A few nursing role descriptions; roles in QI department; included in career ladder program - Materials and minutes from multiple committees and interest groups heavily focused or specifically focused on EBP, some present for over five years - A research group with materials, minutes and reference to EBP; QI groups, some clearly evidence-focused - Descriptions of governance groups, with EBP included in the expectations or activities of the majority - Descriptions of governance groups, with EBP or data included in the expectations or activities of most - Educational and orientation materials, including EBP-related tools, presentations, skill sets - Journal club material, PowerPoint presentation, and orientation description (e.g., re: library services) - Policy/procedure algorithm, researcher audit of related EBP status, and multiple Ps seen linked to evidence; clinical forms for documentation said to be E-B - Policy/procedure algorithm, and Ps seen being linked to evidence; clinical documentation forms said to be E-B Implementation Science 2009, 4:78 http://www.implementationscience.com/content/4/1/78 Page 8 of 19 (page number not for citation purposes) problematic; e.g., ' there was all this data out there and I didn't know where it was coming from. And how it was collected. And what was the strength of this evidence; not evidence but data' (informal leader nine). A general cross-comparison between cases The two cases were clearly different in terms of EBP rela- tive to their organizational context, level of EBP activity, and degree of institutionalization. In general, the role mode site had a pervasive presence of EBP versus an iso- lated presence in the beginner site. Unlike the role model site, the beginner site had only a handful of isolated nurs- ing-led EBP projects or research, some still in the develop- mental stage. Additionally, nursing at the beginner site seemed driven primarily by external demands, traditional QI, and physician-focused initiatives. This was in contrast to the role model site's focus on EBP-related staff-driven issues and professional practice improvements, in addi- tion to external demands. Another distinction between the cases was the clear leadership role played by nursing in EBP activity at the role model organization; in contrast, the most EBP-knowledgeable individuals at the beginner organization were key physicians. Few in nursing at the beginner site appeared to have in-depth knowledge of the concept of EBP or its related processes. Overall, little hard evidence existed that the beginner site's department of nursing was consistently applying evidence to practice according to our study definition; i.e., in terms of a clear search for and systematic use of research find- ings, as well as other evidence but particularly research to improve identified practices or processes within nurs- ing. Evidence suggested that the site was still, on the whole, in the awareness/beginning stages of EBP, with a recurrent reference by site participants to 'beginning' or 'beginning shift' or 'a ways to go.' In terms of the nature of their organizational context rela- tive to EBP receptivity, the two sites were qualitatively dif- ferent. More specifically, based upon accumulation of data from multiple sources and multiple participants, the team observed distinct differences in the extent or degree to which each case had progressed relative to its overall EBP receptivity in contrast to its overall EBP non-receptiv- ity. In turn, the team qualitatively judged those differences on each of Pettigrew et al.'s individual elements [33,34]. While it was not possible to calculate quantitative scores, the team consistently agreed upon estimates of the general level of EBP-related receptivity and non-receptivity, per element, within each site. Figures 2 and 3 visualize these contrasting conditions with a vertical high-low scale to designate the predominance of receptivity and non-recep- tivity conditions. The box in the upper right corner of each Figure contains the level or 'predominance' scale for receptivity/✰ and non-receptivity/✗, as well as the meaning of each type of symbol and arrow. A blank scale, as in the change agenda and its locale, indicates no discernible data regarding the presence and/or influence of that element at the site. The arrows, demonstrating element-to-element relationships, indicate either a positive or negative influence between specific elements as well as either a one-way or interactive relationship. • Dozens related to EBP project activity and related dissemination efforts, internal and external: • List of nursing research activity, including students and outside researchers; a PP hospital-based multidisciplinary project; a few single page PI outline for a improvement activities - Proposals for the human subjects committee decision - PowerPoint (PP) presentations on EBP process and projects - EBP-related project reports, program evaluations, and an EBP newsletter - Publications, including multi-disciplinary ones; and evidence of co-operative networking SURVEY* FOR STAFF NURSES ON THREE EMBEDDED UNITS , with a focus on their unit or self Respondents = 39 Respondents = 21 Response rate = 34% Response rate = 20% SURVEY* FOR ALL IDENTIFIED MEMBERS OF THE LEADERSHIP TEAM , with a focus on the department Respondents = 104 Respondents = 65 Response rate = 56% Response rate = 50% *Tools in surveys: Organizational Learning, Multi-factor Leadership; Practice Environment; and Research Utilization. Table 3: Summary of case site samples (Continued) Implementation Science 2009, 4:78 http://www.implementationscience.com/content/4/1/78 Page 9 of 19 (page number not for citation purposes) As indicated in Figures 2 and 3 overall, and as described in more detail in the following section, the role model site had a more discernible EBP-receptive context and a lower degree of non-receptivity than the beginner site. In con- trast to the beginner site, the role model site demonstrated an interconnected combination of receptive contextual elements that appeared to enhance its ability to effectively and purposively institute and sustain EBP-related change. This included a greater number of more positively linked signs and symptoms/elements of receptivity in the role model site. In the beginner site, despite a positive intent and initial structural efforts, the elements of EBP-related receptivity were not yet operationalized to a sufficient degree to create institutionalization, with the site demon- strating a mixed or patchy context relative to strategic EBP change. Specifically, the beginner site presented a moder- ate to high level of non-receptivity in selected contextual elements, along with a fairly low level of EBP receptivity overall (Figure 3); and there was a greater number of, and stronger, negative linkages than in the role model site. Statistically significant cross-case differences were also evi- dent in all but one of the survey findings (Table 4). Both the overall and sub-scale scores of the PES [40] were sig- nificantly higher in the role model site. This is consistent with qualitative findings where the role model site's lead- ership, culture, and related staff attitudes were found to be more developed in terms of supporting EBP. Trend-wise, further examination indicated that staff in the role model site reported not only higher scores on the PES than staff in the beginner site, but also higher than leaders in the beginner site. In terms of the OLS, used as a proxy for a learning culture [38], the role model site scored signifi- cantly higher than the beginner site. This, too, is consist- ent with interview data and observations regarding a supportive culture. As measured by the MLQ for the CNO and NMs, both sites overall demonstrated transformational leadership. However, scores were significantly higher in the role model site and in the 60th to 70th percentile for four of Role model caseFigure 2 Role model case. Quality and coherence of policy Key people leading change Managerial clinical relations Environmental pressure Cooperative inter-organizational networks Supportive organizational culture Simplicity and clarity of goals Change agenda and its locale    Predominance Receptive Non receptive High Low  negative influence of an X positive influence of a Star Implementation Science 2009, 4:78 http://www.implementationscience.com/content/4/1/78 Page 10 of 19 (page number not for citation purposes) the five subscales. For the beginner site, scores were in the 50 th to 60th percentile on three scores and the 30 th to 40th for two, including intellectual stimulation. This pattern is consistent with and reinforces the qualitative data regard- ing EBP, as transformational leaders define a vision, clearly communicate organizational values, and work to get cohesion among employees relative to organizational values and goals, in this case regarding EBP [42]. The remainder of the Results section below further con- trasts the role model and beginner sites in terms of key themes of receptive capacity. Related details further illu- minate the above general findings. Key contrasting themes Themes that emerged for the most part relate to elements from the Pettigrew et al. framework [33,34]. Additional themes beyond that framework are described last. Key people leading change There were several key types of roles at multiple levels leading change in relation to EBP in the role model's nurs- ing service; e.g., 'I feel that our practice is evidence-based or that our environment is evidence-based because of our leadership, from the CNO [to] having a lot of experts that are really and truly willing to help and support/facilitate those kinds of activities' (informal nurse leader four). Identified by study participants and the research team at the role model site, such key leaders included the CNO, research and education director, clinical directors, NMs, advanced practice nurses (APNs) and staff nurses. For both cases the CNO was a key leader, but in a qualita- tively different way. The CNO at the role model site, who worked very closely with the research and education direc- tor from the start of the effort, was viewed by participants as the key leader and driver of the strategic vision for EBP. As reported by both leaders and staff, this vision was clear Beginner caseFigure 3 Beginner case. Quality and coherence of policy Key people leading change Managerial clinical relations Environmental pressure Cooperative inter-organizational networks Supportive organizational culture Simplicity and clarity of goals Change agenda and its locale    Predominance Receptive Non receptive High Low  negative influence of an X positive influence of a Star  [...]... responsibility for the findings reported in this work and have read and approved the final manuscript CBS took the main role in implementation of the study plan, including site visits, analysis, and drafting of the manuscript All other authors (JR, JR-M, AS, and MC) actively participated in analysis of data, interpretation of data, revision of the manuscript, and support of overall implementation JR and AS briefly... primary care: an observational study Qual Saf Health Care 2003, 12(4):273-279 Damanpour F: Organizational innovation: a meta-analysis of effects of determinants and moderators Acad Manage J 1991, 34(3):555-590 Oranta O, Routasalo P, Hupli M: Barriers to and facilitators of research utilization among Finnish registered nurses J Clin Nurs 2002, 11(2):205-213 Ring N, Malcolm C, Coull A, Murphy-Black T, Watterson... Managing Change in the NHS: Organisational Change: A Review for Health Care Managers, Professionals and Researchers London: National Co-ordinating Centre for NHS Service Delivery and Organisation R & D; 2001:1-101 Pettigrew AM: The Character and Significance of Strategy Process Research Strategic Management Journal 1992, 13(8):5-16 Pettigrew A, Ferlie E, McKee L: Shaping Strategic Change The Case of the... disentangle the elements of culture in various units such that identifying one particular configuration of a culture that enabled research use was not possible Lukas et al [49] also cite culture as a key organizational component in sustainability of organization transformation Our findings suggest that organizational culture is a contextual determinant of EBP institutionalization As such, we argue that strategic. .. context for change: 'A combination of factors from both the inner and outer context that together determine an organization's ability to respond effectively and purposively to change [2] 6 7 8 9 10 11 12 • Strategic: Refers to planned, organizational approaches to change and its deliberate management • Sustainability: Changes (practice and outcomes) based on evidence that continue over time as related to... findings and the role of key people leading change are not confined to nursing Other disciplines and healthcare organizations appear to have the same challenges and needs relative to EBP, innovation, or strategic service change [5,49] For example, Lukas et al [49] found that leadership from top to bottom of an organization is a critical 'driver' of strategic organizational change focused on improvement of. .. the patient and myself and, again, that visibility and someone who is approachable every day and not that the people that are in place aren't helpful, it's again, probably having enough availability of experts' (formal leader seven) In terms of the internal nursing and hospital environment, in the beginner site, staffing was viewed differently by staff versus key leaders Staff nurses recurrently expressed... Money & Management 1992, 12(3):27-31 Pettigrew A, Ferlie E, McKee L: Shaping Strategic Change: Making Change in Large Organizations: The Case of the National Health Service London: Sage Publications; 1992 Mares P: How health authorities learn: a review of literature Center for Innovation in Primary Care 1998 [http://www.innovate.org.uk/ frameset.asp?Link=Library] Accessed January 2007 Yin RK: Case Study. .. conceptual framework Qual Saf Health Care 2002, 11(2):174-180 Lukas CV, Holmes SK, Cohen AB, Restuccia J, Cramer IE, Shwartz M, Charns MP: Transformational change in health care systems: an organizational model Health Care Manage Rev 2007, 32(4):309-320 Stetler CB: Role of the organization in translating research into evidence-based practice Outcomes Manag 2003, 7(3):97-103 quiz 104-105 Wallin L, Ewald... which practice takes place; characterized by organizational culture, leadership, basic organizational components, and type of clinical setting ‫ ؠ‬Pettigrew/Whipp: an essential dimension or the WHY/motivation behind strategic change to EBP and related enablers/barriers • Content: One of Pettigrew/Whipp's essential dimensions, in this case the WHAT of strategic change; i.e., the • Institutionalization: . self behavior (RU). Analysis Qualitative data analysis Data were analyzed within site-specific data sets and then triangulated across site-specific data sets before making comparisons across sites. Analyses. contains the level or 'predominance' scale for receptivity/✰ and non-receptivity/✗, as well as the meaning of each type of symbol and arrow. A blank scale, as in the change agenda and. Sibbald B: Team structure, team climate and the quality of care in primary care: an observa- tional study. Qual Saf Health Care 2003, 12(4):273-279. 16. Damanpour F: Organizational innovation: a